Ophthalmoscopy

Being able to use an ophthalmoscope is a very useful skill in primary care, perhaps for one reason above all

exclude raised intracranial pressure

The current British Association for the Study of Headache (BASH) guidelines (page 17) state that

Fundoscopic examination is mandatory in first consultation with headache, and it is always worthwhile to repeat it at during follow up

By viewing a normal optic disc, or better still, observing spontaneous veinous pulsation, raised intracranial pressure can be effectively excluded. It is reassuring to doctor and patient alike.

Tips for success:

Explain what you are doing

Turn off the lights

Get the patient looking at a distant object, and advise them to try not to look at you when you get in the way.

Set the lens to zero for most people

Aim for the middle of the head, from around 4cm away (very close)

Remember that the longer you take to examine, the more comfortable the bright light becomes for the patient. Take your time.

What about using dilating eye drops? They are great!

Except where

The patient is driving

The patient needs neurological observation (e.g. head injury)

Complications are extremely rare, so simply ‘safety net’ after dilating.

The dilating drops normally wear off after 2-3 hours, and your vision should return to normal. If you develop brow-ache, nausea or cloudy vision go to hospital.

I have seen very few people with acute glaucoma triggered by dilating drops, despite the many thousands that have them used each year in eye clinics. It cannot be triggered in patients who have had cataract surgery, and almost all patients with known glaucoma are not at risk of angle closure.